USAID Investments in Avian Influenza Preparedness and Response: The Case of Ghana

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USAID Investments in Avian Influenza Preparedness
and ResponseThe Case of Ghana

• BethAnne Moskov
• HPN Officer, USAID/Ghana
• December 2007

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Presentation Outline

• Why Ghana is Valuable as a Case Study
• Pre-Outbreak Investments (10/05-4/07)
• The Outbreak Response (since 4/07)
• Is Ghana a Success Story?
• Plans for the Future

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Interest in Ghana as a Case Study

• Only Ghana Bangladesh invested prior to an AI
  outbreak.
• Only Ghana engaged multiple partners.
• 400,000 total pre-outbreak over 1.5 years
• 710,000 committed since outbreak April 07
• 1,290,000 more planned for FY08
• Which is the better gamble
• To Invest Prior - Risk Wasting Resources? (Ghana)
• To Play Catch Up - Risk Ineffectiveness? (Others)
• Which Investments Most /Least Valuable?

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Pre-Outbreak Investments National AI Working
Group

• Sparked the formation of AIWG Oct 05
• Major players VSD, GHS, NADMO, FAO, WHO, USAID
  partners (QHP, GSCP), UNICEF, others
• Lacks official mandate, power
• Useful role in coordination and info sharing
• For USAID good venue to obtain info, gauge
  needs, air proposals, exercise leadership,
  introduce our parade of new faces

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Pre-Outbreak Investments AI Preparedness Plan

• Supported development of National AI Preparedness
  Response Plan in Oct-Dec 05, based on WHO
  template for epidemic Phases 2-6
• 91 action points calling for 6.2 million
  investment over 5 months.
• Some not realistic.
• About one-quarter of total budget funded as of
  October 2006.
• Useful pre-outbreak to galvanize and organize
• USAID supporting revision of the plan

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Pre-Outbreak Investments Training

• 3 rounds of training for all vet officers.
• Cairo training for Virologists to establish
  National AI laboratory at Noguchi
• Additional training and capacity building
  exercises for vet services, the MOH, customs
  agents, etc.
• Active surveillance training manual developed and
  used in field
• WHO and FAO also supported training

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Pre-Outbreak Investments Active Surveillance

• Supported 2 rounds of active surveillance
  throughout the country
• 3 teams of 5 members each (4 tech and 1 driver)
• Nearly 2000 wild birds and poultry sampled,
  results published (all negative)
• Epidemiologically a low yield exercise.
• Expensive and questioned at the time.
• But excellent value in retrospect as a dress
  rehearsal.
• Boosted confidence, developed skills and systems.

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Pre-Outbreak Investments Commodities

• PPEs, laboratory supplies, mist nets for active
  surveillance
• 75,000 worth of items for several MDAs
• FAO contributed 45,000 in commodities
• Commodities were used quickly when outbreak
  occurred.
• Allowed enough time to bring in more.
• WHO contributed Tamiflu 100,000 tablets, 500
  pre-positioned to each region.
• Not used yet by GHS for suspected cases or high
  risk exposures - in spite of our prompting.

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Pre-Outbreak Investments Communications

• Sponsored a national campaign to reduce public
  panic following announcement of H5N1 in Nigeria
• Provided TA and leadership on the AIWG
  communications sub-committee
• Ten regional press briefings and community
  theatre in each region
• 30,000 investment

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Pre-Outbreak Investments Communications

• Press Kits
• Fact Sheets
• Cartoon Strips
• Radio Quiz
• Radio Mentions (5-10 seconds) spots
• Chicken Recipes
• Tidbits on the Bird Flu

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Pre-Outbreak Investments Diagnostics at Noguchi

• NAMRU/Noguchi established national influenza lab
  Real-time PCR diagnosis of H5N1 for 300,000.
• Opened in April 2007.
• 4 days later, diagnosed H5N1 in Ghana.
• 7 weeks later, did same for Togo!
• Saved days/weeks in initial response.
• Tested 10 human samples during outbreaks (all
  negative).
• Underused after that, collaboration issues with
  the National vet lab
• CDC may fund human surveillance study at Noguchi.
  
• USAID mission endorses idea.

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Pre-Outbreak Investments

• Lower Priorities in Retrospect
• Wildlife services
• Migratory bird theory fading.
• Testing is low yield.
• But important to keep them at table
• NADMO
• Relatively ineffective due to lack of political
  backing
• Health facilities
• Plans for isolation rooms in 12 hospitals are
  cost-ineffective for Phase 2-4.
• Misplaced, in system that resists putting even
  face masks on active TB patients.
• Recommend ratio of 91 or 82, for vet vs. human
  investments

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Outbreak Response

• Three Outbreak Areas Tema, Sunyani, Aflao

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Outbreak Response Tema

• Index farm identified 4/26/07.
• Cluster of additional farms found 9 km away by
  active surveillance
• Key control measures were taken with speed and
  confidence
• Diagnosis, culling, informing the public, putting
  bans into place.

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Outbreak Response Tema

• Technical quality of the operations was quite
  good, though information gathering, coordination
  had faults.
• Transparency was good- Ghana not hiding its
  problem.
• Public health teams were involved early.

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Outbreak Response Tema

• Partners brought in help quickly
• DELIVER sent 2 cluster management packs in 4 days
• NAMRU flew AI samples to Cairo
• CDC on the scene with 3 experts during first 4
  weeks
• WHO was in the field supporting human
  surveillance within days
• GSCP had communications campaign developed and
  running within 3 weeks (NGO trainings, road
  shows, print materials, radio spots)

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Outbreak Response Tema

• After 3 weeks, no further cases have been
  detected in the area
• Tema response demonstrated value of preparedness

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Outbreak and Response Tema

• Challenges
• Chickens were sold from farms that were under
  surveillance.
• Law enforcement role was weak, even
  obstructionist.
• Breakaway poultry farmers sought to cast doubt on
  government approach.
• Compensation of farmers was delayed, contentious.

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Outbreak and Response Tema

• Challenges (cont)
• China, Vietnam Togo have authoritarian AI
  responses. Whats good for democracy may be bad
  for AI control?
• Harsh field conditions were the real human health
  concern.
• Ghana arguably had a human AI casualty, the
  dedicated vet epidemiologist Dr. Karimu.
• Communications campaign may have had an
  overemphasis on poultry-to-human transmission

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Outbreak Response Sunyani

• Index farm was 5/23/2007.
• Additional farm found on active surveillance
• Culling was aggressive, but decontamination was
  left to farmers who had poor technique and
  bio-safety.

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Outbreak Response Sunyani

• Human health monitoring was vigorous.
• Coordination between various agencies was
  efficient, easy, better than at national level
• Diagnosis was by rapid test, but confirmation as
  H5N1 was delayed due to lab mislabeling and
  delays.
• Vet services required close support from National
  Teams.
• Regional institutions are resource poor, hungry
  for training

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Outbreak Response Aflao Togo

• One farm in Aflao, on Togo border, reported
  affected on 6/22/07.
• Regional vet team reacted with confidence, good
  technique, had PPEs, showed fair AI knowledge
• Human monitoring was timely
• Togos first case found the same week, on farm at
  Benin border (45 km east of Aflao).
• Ghana assisted Togo with transfer of PPEs and
  processing of lab samples at VSD and Noguchi
• Again, good evidence of preparedness paying off

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Outbreak Response USAID Support

• Operations Capacity Building - 350,000
  through QHP.
• Communications - 150,000 through GSCP targeting
  Tema regions
• NADMO supported to establish a bird flu hot line
  and control room

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Outbreak Response USAID Support

• CDC experts (3) for needs assessment, training,
  advising
• STOP AI personnel (5) for commodities training,
  logistics, veterinary advising
• Commodities rapid deployment of gt4500 PPEs, 40
  decon kits, gt100 rapid antigen tests. DELIVER
  helping

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Outbreak Response USAID Support

• Advocacy
• U/S Fores visited the VSD compound 7/17/07
• USAID mission is working with MOFA, WHO, FAO to
  increase AI profile and improve donor
  coordination
• Challenges
• Coordination inter-agency and inter USAID (CRSP),
• Need to continuously work at maintaining
  relations with GOG partners.
• Coordinating and supporting so many short-term
  TA.
• Harmonizing mission needs and plans with the
  regional and global priorities.

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Is Ghana a Success Story?

• Situation has calmed
• Outbreaks have been identified and stamped out
  quickly 3 in succession. No sustained
  transmission.
• Human monitoring and surveillance fair, with no
  human cases so far.
• Public has remained calm. Poultry consumption is
  steady. Media generally cooperative.
• Farmers interested in biosecurity upgrades.
• MOFA stepped up with high level plan and
  enthusiastic for restructuring the poultry
  industry

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Is Ghana a Success Story?

• New Friends and Old
• A maturing partnership with VSD.
• Old partners performing well.
• New partners, i.e. DAI, AED (AI.COMM), CDC,
  making a good first impression
• AI site visit of U/S Fore very positive -- helped
  to cement the deepening ties with Vet Services
• EU stepping up. Coming to us for advice.
• Togo turning to Ghana for advice and support

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Is Ghana a Success Story?

• Some Nagging Doubts
• How much AI is actually out there?
• Surveillance weak.
• Many recommendations plans not yet acted on.
• Poultry practices, human health facilities still
  woefully lacking.
• Regional vet capacities are weak.
• Epidemiology still poorly understood.
• At least 2 strains of virus in country.
• Road links emerging as important.
• West African borders highly porous and neighbors
  not transparent. High risk of re-infection?

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Keys to Success

• USAID/Ghana has taken the AI threat seriously
• Many useful investments in preparedness
• USAID vision, willingness take lead become
  directly involved
• Good working relationships with key local players
• Flexibility, with periodic re-prioritization of
  support
• Available mechanisms to provide quick inputs
  (QHP, GSCP)
• Field support DELIVER, STOP AI, AI.COMM
• USAID leadership supportive at mission natl
  levels

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The Way Forward

• Transitioned from preparedness to response
• Now out of crisis mode, planning for longer term
• Strategy taps country experience, GOG plans, AFR
  Bureau AI Unit guidance
• Budget matrix a useful tool to capture all
  emerging program components
• Stage 1 The Emergency Response
• Stage 2 The 12-month Plan

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The 12 Month Plan (Oct. 2007-Sept. 2008)
ANIMAL HEALTH Target 80
HUMAN HEALTH Target 20
Other Program Components
STOP AI 700k
QHP 190k
Commodities Deliver Project
USAID/W Support AFR Bureau, AI Unit
Phase 6 Activities USAID/W-centered
USAID/Ghana EG Team Funding
Pillar 1 Surveillance
Pillar 2 Preparation
Pillar 3 Response Containment
50k
AI.COMM 200k
Pillar 4 Communications
PSC/FSN Mechanism 120k 30k
120k
Staff
Sub-totals 1,020,000
270k
TOTAL 1,290,000
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Take Home Points

• Preparedness planning is essential
• Need to be clear on roles and responsibilities
  before an outbreak occurs
• Important to have single point of contact for USG
  response in country
• Clear communications on who is who and who does
  what

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• Thank you !